How raw referral letters made a case for change

29 May 2009

Dr Carl Parker, professional executive committee chair at Hartlepool PCT and former Hartlepool PBC group chair, explains how simple information can be enough to effect change when it comes to referrals

Dr Carl Parker, professional executive committee chair at Hartlepool PCT and former Hartlepool PBC group chair, explains how simple information can be enough to effect change when it comes to referrals

When we first looked at dermatology, it was quickly apparent that 60% of people in outpatients were seen once or twice and then discharged, meaning there was the potential to shift a very high level of activity.

I knew from the quarterly activity data what GPs were referring for and I knew from the hospital what the final diagnosis was. But I wanted to get at the journey from primary care, and get a sense of why GPs were referring, rather than just the usual hospital data.

I carried out a quick review of referrals to our local acute hospital, University Hospital of Hartlepool, part of North Tees and Hartlepool FT. This was not a formal statistical analysis. I asked the trust for the actual referral letters covering a three-month period, with all the patient and individual GP identifiable information removed. I am a PCT executive member and work for the PCT four days a week, but any other GP could ask their acute trust for the same information.

Potential

Once I had sorted the paperwork into different diagnoses, it showed there was a lot of potential.

I estimated that perhaps 30-35% of referrals could have been managed differently and retained in primary care – from plantar warts to alopecia, acne not requiring Roaccutane to psoriasis managed with topical treatments. Most of these patients were referred with a diagnosis rather than requiring a diagnosis, so there was little need for consultant input.

There was considerable variation between practices – 10% of total referrals appeared to come from just one practice – but many patients hadn't been tried on normal first- or second-line primary care treatment.

With a population of 93,000, there just wasn't the scope in Hartlepool to set up an alternative to the hospital outpatient service, but it was worth investigating other ways of bringing down unnecessary attendance and ensuring as much as possible was managed within primary care.

The PBC group was keen to manage demand more effectively, so when I presented the information there was ready agreement that an educational programme might be helpful. Relationships between GPs and the PCT were much better than in many other areas – Department of Health surveys show Hartlepool and Stockton achieve the highest ratings in the North-East.

Education

We ran three education sessions over the course of a year – two in the first six months, with a mop-up session six months later.

It's cheaper to run mass education sessions rather than putting someone in each practice on training courses, so it made sense to run town-wide sessions. It was more efficient to run large workshops as long as enough people turned up. Each session cost around £3,000 to run.

I drew up a business case and got funding from the PCT and sponsorship from three pharmaceutical companies to cover the rest of the costs. We made it clear the companies were not allowed to promote anything not in the guidelines.

The workshops were led by local dermatology consultants who were keen to promote the local guidelines they'd produced and for the opportunity to have a face-to-face conversation with colleagues and see the guidelines taken up.

Almost every GP in the town attended – in fact we pretty much closed all the surgeries for each of the three days and used the out-of-hours service for cover. The pharma sponsorship helped pay for this cover. Each session involved three to four presentations with questions and answers as we went along, as there is nothing worse than being lectured at for hours on end.

Results

After the training sessions ended, the PBC group formally adopted the local guidelines for management in primary care developed by consultants from Hartlepool University Hospitals.

We plotted the impact over the following year and referrals fell by 18%, saving £25,000, so the project more than paid for itself. The reduction in referrals also cut hospital waiting times.

There would have been no point arranging an education session without some evidence that there was an education need. Getting the referral letters made all the difference as it meant we could target the education more carefully.

You have to know what is going into the hospital, rather than just the outcomes data – what is happening from the GP end? Turning to the wider problem of difficulty getting data to support PBC, I think GPs can be too scientific in their approach to data as they are used to working with an evidence base.

They ask for more and more data but I'm not convinced they always need what they think they need. I think GPs could be more pragmatic in their approach. A nirvana of 98% [proof] is unlikely – 80% is enough to change things.

Seeing the referral letter was key to tackling the problem. Formal diagnosis coding doesn't tell you why patients end up in hospital.

Once you have that, you can design your own method to demonstrate your outcomes and create measurements based on what's pertinent to your locality. But if you search for that information at the outset you will struggle to find it.